Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review.

OBJECTIVE: To assess characteristics and outcomes of young children receiving intensive multidisciplinary intervention for chronic food refusal and feeding tube dependence. STUDY DESIGN: We conducted a retrospective study of consecutive patients (birth to age 21 years) admitted to an intensive multidisciplinary intervention program over a 5-year period (June 2014-June 2019). Inclusion criteria required dependence on enteral feeding, inadequate oral intake, and medical stability to permit tube weaning. Treatment combined behavioral intervention and parent training with nutrition therapy, oral-motor therapy, and medical oversight. Data extraction followed a systematic protocol; outcomes included anthropometric measures, changes in oral intake, and percentage of patients fully weaned from tube feeding. RESULTS: Of 229 patients admitted during the 5-year period, 83 met the entry criteria; 81 completed intervention (98%) and provided outcome data (46 males, 35 females; age range, 10-230 months). All patients had complex medical, behavioral, and/or developmental histories with longstanding feeding problems (median duration, 33 months). At discharge, oral intake improved by 70.5%, and 27 patients (33%) completely weaned from tube feeding. Weight gain (mean, 0.39 ± 1 kg) was observed. Treatment gains continued following discharge, with 58 patients (72%) weaned from tube feeding at follow-up. CONCLUSIONS: Our findings support the effectiveness of our intensive multidisciplinary intervention model in promoting oral intake and reducing dependence on tube feeding in young children with chronic food refusal. Further research on the generalizability of this intensive multidisciplinary intervention approach to other specialized treatment settings and/or feeding/eating disorder subtypes is warranted.

The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial.

OBJECTIVE: To assess the feasibility and initial efficacy of a structured parent training program for children with autism spectrum disorder and moderate food selectivity. STUDY DESIGN: This 16-week randomized trial compared the Managing Eating Aversions and Limited variety (MEAL) Plan with parent education. MEAL Plan (10 core and 3 booster sessions) provided parents with nutrition education and strategies to structure meals and expand the child's diet. Parent education (10 sessions) provided information about autism without guidance on nutrition, meal structure, or diet. In addition to feasibility outcomes, primary efficacy outcomes included the Clinical Global Impression - Improvement scale and the Brief Autism Mealtime Behaviors Inventory. Grams consumed during a meal observation served as a secondary outcome. RESULTS: There were 38 eligible children (19 per group, 32 males). For MEAL Plan, attrition was <10% and attendance >80%. Therapists achieved >90% fidelity. At week 16, positive response rates on the Clinical Global Impression - Improvement scale were 47.4% for the MEAL Plan and 5.3% for parent education (P < .05). The adjusted mean difference (SE) on Brief Autism Mealtime Behaviors Inventory at week 16 was 7.04 (2.71) points (P = .01) in favor of MEAL Plan. For grams consumed, the adjusted standard mean difference (SE) was 30.76 (6.75), also in favor of MEAL Plan (P = .001). CONCLUSIONS: The MEAL Plan seems to be feasible, and preliminary efficacy results are encouraging. If further study replicates these results, the MEAL Plan could expand treatment options for children with autism spectrum disorder and moderate food selectivity. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02712281.

Avoidant/restrictive food intake disorder: A diagnosis at the intersection of feeding and eating disorders necessitating subtype differentiation.

Avoidant/restrictive food intake disorder (ARFID) is a diagnosis that sits squarely at the cross roads of feeding disorders and eating disorders. It is historically tied to feeding disorders as a replacement of the DSM-IV diagnosis of feeding disorder of infancy or early childhood. The revision process, however, extended the diagnostic umbrella by removing its predecessor's weight loss requirement and age of onset restriction (i.e., 6 years). Implications of this extension include capturing an older cohort of patients with ARFID accessing care at eating disorders clinics, as well as providing a diagnostic home to previously orphaned pediatric subgroups with feeding disorders that lacked a diagnostic home prior to DSM-5. While recognizing notable strengths of this now 5-year-old diagnostic entity, ARFID is largely recognized as a very heterogeneous condition that lacks specificity to best guide clinical and research activities. The current commentary discusses the implications of ARFID as a replacement and extension of the DSM-IV diagnosis of feeding disorder of infancy or early childhood and provides the rationale and guidance for developing a subtype taxonomy.

Radcliffe ARFID Workgroup: Toward operationalization of research diagnostic criteria and directions for the field.

OBJECTIVE: Since its introduction to the psychiatric nomenclature in 2013, research on avoidant/restrictive food intake disorder (ARFID) has proliferated highlighting lack of clarity in how ARFID is defined. METHOD: In September 2018, a small multi-disciplinary pool of international experts in feeding disorder and eating disorder clinical practice and research convened as the Radcliffe ARFID workgroup to consider operationalization of DSM-5 ARFID diagnostic criteria to guide research in this disorder. RESULTS: By consensus of the Radcliffe ARFID workgroup, ARFID eating is characterized by food avoidance and/or restriction, involving limited volume and/or variety associated with one or more of the following: weight loss or faltering growth (e.g., defined as in anorexia nervosa, or by crossing weight/growth percentiles); nutritional deficiencies (defined by laboratory assay or dietary recall); dependence on tube feeding or nutritional supplements (≥50% of daily caloric intake or any tube feeding not required by a concurrent medical condition); and/or psychosocial impairment. CONCLUSIONS: This article offers definitions on how best to operationalize ARFID criteria and assessment thereof to be tested in existing clinical populations and to guide future study to advance understanding and treatment of this heterogeneous disorder.

Intensive, Manual-based Intervention for Pediatric Feeding Disorders: Results From a Randomized Pilot Trial.

OBJECTIVES: The aim of this pilot study was to investigate feasibility and preliminary efficacy of an intensive, manual-based behavioral feeding intervention for children with chronic food refusal and dependence on enteral feeding or oral nutritional formula supplementation. METHODS: Twenty children ages 13 to 72 months (12 boys and 8 girls) meeting criteria for avoidant/restrictive food intake disorder were randomly assigned to receive treatment for 5 consecutive days in a day treatment program (n = 10) or waitlist (n = 10). A team of trained therapists implemented treatment under the guidance of a multidisciplinary team. Parent training was delivered to support generalization of treatment gains. We tracked parental attrition and attendance, as well as therapist fidelity. Primary outcome measures were bite acceptance, disruptions, and grams consumed during meals. RESULTS: Caregivers reported high satisfaction and acceptability of the intervention. Three participants (1 intervention; 2 waitlist) dropped out of the study before endpoint. Of the expected 140 treatment meals for the intervention group, 137 (97.8%) were actually attended. The intervention group showed significantly greater improvements (P < 0.05) on all primary outcome measures (d = 1.03-2.11) compared with waitlist (d = -1.13-0.24). A 1-month follow-up suggested stability in treatment gains. CONCLUSIONS: Results from this pilot study corroborate evidence from single-subject and nonrandomized studies on the positive effects of behavioral intervention. Findings support the feasibility and preliminary efficacy of this manual-based approach to intervention. These results warrant a large-scale randomized trial to test the safety and efficacy of this intervention.

Multidisciplinary feeding treatment for a patient with interstitial lung disease.

Children with underlying medical and developmental conditions often present with complications that include feeding difficulties. Severe feeding difficulties may meet the criteria for the psychiatric diagnosis of Avoidant Restrictive Food Intake Disorder (ARFID). ARFID is a disruption in feeding/eating which may include weight loss/faltering growth, nutrient deficiencies, and/or reliance on a nutritionally complete formula to meet caloric needs. Children with interstitial lung disease (ILD), have a higher prevalence of feeding problems than the general population. To date, no published literature exists to provide guidance for treating severe feeding difficulties experienced by children with ILD. In this paper, we present an encounter in which we safely and effectively treated ARFID as evidenced by underweight and dependence on a nutritionally complete formula in a 3-year-old male with ILD using a multidisciplinary approach to treatment. Before the admission, the patient relied primarily on oral nutritional supplementation for most of his nutritional needs and therapeutic efforts to advance food intake were complicated by mealtime behavior problems and concerns regarding swallow safety. Intervention introduced 16 new foods, established consistent caloric intake of target food, and successfully weaned the patient from bottle feeding. We also review special considerations and provide guidelines for adapting treatment at multidisciplinary programs for patients with complex cardiorespiratory disease including modifications to behavior management procedures, medical monitoring, and nutritional consultation.